Screening Mammography: Is the Sacred Cow headed to Morton's?

In a blog Dr. Presant discusses a new study

Just ordering a mammogram has been simple, instantaneous, and no need for much counseling. And because of its simplicity, this needed only a low level office visit.

But the publication of the results of 10 years follow up in the NCI funded Breast Cancer Surveillance Consortium (BCSC) in Annals of Int Med 2011; 155: 481 by R.A. Hubbard and coauthors teaches us a different process is medically necessary.

In the 169,456 women who had their first mammogram between 1994 and 2006 with annual re-screening mammograms, by 10 years an astounding 61.3% had been returned at least once for a false positive recall exam. Also,  7% (1 woman in 14) had a biopsy recommended and performed which was a false positive.

Since recall exams and biopsies are most stressful for both the patient as well as their spouse, friends or family, more counseling by us when we order a mammogram is necessary. Awareness of the high frequency of false positive recalls and biopsies can reduce stress and apprehension, while still maintaining the currently recommend frequency of screening to detect early stage, more highly curable cancers. When documented in the medical note, such counseling and discussion should result in higher level codes for such visits. 

Without such guidance by us, compliance with annual mammography schedules will reduce and later stage cancers will increasingly be diagnosed. We should implement this discussion with our patients, their families, and in our communities at, for example, tumor board discussions about breast cancer patients.

However I would look at the 'problem' as an opportunity....

We are in an era of targeted therapy - tailoring the treatment to the patient's specific cancer. Shouldn't we be doing targeted screening - performing risk assessment on all patients (Tyrer-Cusick, Gail, BrevaGen (SNP analysis)) and then putting our resources toward the appropriate patient's risk (and away from the lower risk patients)? This would increase true positive biopsies and markedly decrease the denominator (removing the low risk patients) which would increase specificity. We have to let the sacred cow of screening mammography for all women go out to pasture....